Male Urinary Tract (IPSS) If you have been advised by the surgery to submit Male Urinary Tract (IPSS) review please use this form. Name First Last Date of Birth Day Month Year PhoneEmail Enter Email Confirm Email Urinary Tract ReviewOver the past month, how often have you had a sensation of not emptying your bladder completely after you finish urinating? Almost always More than half the time About half the time Less than half the time Less than 1 in 5 times Not at all Over the past month, how often have you had to urinate again less than two hours after you finished urinating? Almost always More than half the time About half the time Less than half the time Less than 1 in 5 times Not at all Over the past month, how often have you found that you stopped and started again several times when you urinated? Almost always More than half the time About half the time Less than half the time Less than 1 in 5 times Not at all Over the past month, how often have you found it difficult to postpone urination? Almost always More than half the time About half the time Less than half the time Less than 1 in 5 times Not at all Over the past month, how often have you had a weak urinary stream? Almost always More than half the time About half the time Less than half the time Less than 1 in 5 times Not at all Over the past month, how often have you had to push or strain to begin urination? Almost always More than half the time About half the time Less than half the time Less than 1 in 5 times Not at all Over the past month, many times did you most typically get up to urinate from the time you went to bed until the time you got up in the morning? 5 times or more 4 times 3 times 2 times 1 time None If you were to spend the rest of your life with your urinary condition just the way it is now, how would you feel about that? Delighted Pleased Mostly satisfied Mixed: Equally satisfied/dissatisfied Mostly dissatisfied Unhappy Terrible I confirm that the information provided is accurate to the best of my knowledge